contracts and disappears in 1–2 weeks. This technique provides an instant rejuvenation, particularly around the eyes (Fig. 27.25).

Midface

Traditional rhytidectomy procedures that include resection, retraction, or plication of the SMAS often do not achieve optimal elevation of the malar fat pad and midface. The triangular malar fat pad is oriented

with its base along the nasolabial fold and apex over the zygoma. It is superficial to the medial part of the SMAS and adherent to the overlying skin. Retracting the SMAS in this region does not elevate the malar fat pad and may deepen the nasolabial fold. Repositioning the malar fat pad using the suture suspension technique restores the beauty triangle of the face, softens the nasolabial fold, and reduces the lower lid length (Fig. 27.26). The vector of lift to achieve this is superolateral. Three punctures are made: two in the temporal hairline over the temporal

Fig. 27.26 Closed suture suspension of the malar fat pad. (a) A point is marked just lateral to the nasolabial fold and two points in the temporal hairline. The markings represent the proposed course of the suture to lift the malar fat pad in a superolateral vector. (b) Lidocaine with epinephrine is infiltrated subcutaneously along the marked lines. (c) Using a #11 blade, stab incisions are made at the three points. (d) The dermis is fully penetrated at the inferior incision to minimize dimpling of the skin. (e) The curved needle is passed along the lower line from the posterior temporal incision and exits at the incision lateral to the nasolabial fold. (f) A USP#4 polycaproamide suture, together with a 3–0 Vicryl suture, are passed through the eye of the needle and withdrawn to the temporal incision. (g) The needle is passed from the anterior temporal incision along the other line and receives the ends of the sutures. (h) The needle and sutures are withdrawn, creating a loop around the malar fat pad. (i) The Vicryl suture is grasped and a sawing motion is used to cut through any dermal attachments at the inferior puncture until the skin is smooth. The Vicryl suture is then removed. (j) The needle is passed between the temporal incisions, below the deep temporal fascia, and the polycaproamide sutures are brought through one incision. (k) The sutures are lifted gently to elevate the malar fat pad, and tied. The punctures are allowed to heal by secondary intention. A Steristrip or 6–0 suture is used to seal the puncture at the nasolabial fold

a

b

c

d

e

f

fascia and one just lateral to the nasolabial fold. An artery forceps is inserted into the incision at the nasolabial fold to make sure the incision has passed thoroughly through the dermis. Using the curved needles, a USP#2 or USP#4 polycaproamide suture is passed from the nasolabial fold incision to the temporal incisions, forming a sling around the malar fat pad. A braided suture such as Vicryl can be passed together with the polycaproamide suture. This second suture is used to cut through the dermis or other connections to the skin that might cause a depression or dimple at the nasolabial fold incision. Once the skin is smooth at the site of lifting, the Vicryl suture

is removed and the remaining suspension suture sits in place. The suture is then anchored beneath the deep temporal fascia using the curved needles. As well as lifting the malar fat pad superiorly, it projects anteriorly and improves infraorbital volume loss (Fig. 27.27).

Lower Face

Descent of the lower face and jowls obscures jawline definition and changes the shape of the face from a desirable inverted triangle or heart-shape to

an undesirable rectangular one (Fig. 27.28). To lift the jowls, the zygomatic extension of the SMAS is lifted using an absorbable non-barbed suture and anchored to temporalis fascia above the ear. Three points are marked: two above the ear in the hairline and one just below the zygomatic arch in front of the lobule of the ear. Lidocaine with adrenaline is infiltrated in the subcutaneous plane between the three points, and deeper on the periosteum between the upper two points. Stab incisions using a #11 blade are made at the three points. The tip of an artery forceps is used to puncture through the entirety of the dermis at the lower point to reduce the likelihood of dimpling. A curved needle is passed subcutaneously from the upper anterior incision downward toward the lower incision. At the level of the zygomatic arch, a slightly deeper bite is taken to catch the SMAS. It is important to stay within 8 mm from the external acoustic meatus at this level to avoid injury to the facial nerve. The nerve always passes over the zygomatic arch between 8 mm and 3.5 cm from the external acoustic meatus and usually about 2.5 cm from it [35]. After biting SMAS, the needle comes superficially and exits through the lower incision and the suture is passed through the eye of the needle. The needle is withdrawn and a similar maneuver is made in order to pass the suture from

the lower incision to the upper lateral incision. The needle is then passed deeply into the upper lateral incision to catch the periosteum under the temporal fascia and exits from the upper medial incision to receive the suture end. In the correct position under this deep fascia, any movement of the needle should rock the patient’s head. The suture end is brought through to the upper lateral incision where the two ends can be lifted gently and tied. The lifting of the zygomatic extension of the SMAS as well as the attached overlying skin should smooth the jawline and even lift part of the neck (Fig. 27.29). Any dimpling or inversion of skin at the puncture sites is released using the tip of an artery forceps. Some bunching in front of the ear is normal and resolves spontaneously in 1–2 weeks.

Neck

Mild to moderate ptosis of the neck can be treated using suture lifting alone, or in combination with lipoplasty to remove fat under the chin, along the jawline and in the jowls (Fig. 27.30). The suture suspension technique using absorbable sutures is simple and quick. After infiltrative local anesthesia, two skin punctures are made: one behind the ear over the mastoid and one in the upper neck over the anterior border of the